Provider Demographics
NPI:1871879734
Name:KAMATH, SHANTARAM
Entity type:Individual
Prefix:MR
First Name:SHANTARAM
Middle Name:
Last Name:KAMATH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11357 IVYWOOD TRL
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55129-7758
Mailing Address - Country:US
Mailing Address - Phone:651-436-7130
Mailing Address - Fax:
Practice Address - Street 1:1665 WHITE BEAR AVE N
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55106-1611
Practice Address - Country:US
Practice Address - Phone:651-251-1933
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-24
Last Update Date:2011-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN118810183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist